ASTHMA Flashcards
differentials off SOB in young person ? OTHER THAN ASTHMA ?
pneumonia/ LRTI
PNEUMOTHORAX
PULMONARY HYPERTENSION
consideration when admitting someone with asthma ?
classify the asthma
moderate
severe
life threatening
near fatal
moderate asthma classified as ?
PEFR 50-75 percent of best value or predicted
speech is normal
RR <25
PULSE IS LESS THAN 110
severe asthma classified as ?
PEFR 33-50 percent of best or predicted
cant complete sentences
RR>25
pulse >110
life threatening asthma classification ?
PEFR <33 percent of best value or predicted
oxygen saturation less than 92 percent
normal PCO2
silent chest
syanosis
bradycardia
dysarthria
hypotension
exhaustion
confusion or coma
classification of near fatal ?
‘Near-fatal asthma’, is also recognised characterised by a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures
A-E assessment for asthma ?
see if it is safe to approach and done the appropriate PPE
check airways - can the patient talk to me , talk in full sentences are hard to complete sentences and if there is feeble effort
if i feel like there is any concern of maintaining the airways i would call for help from the arrest team in 2222
B - check if the trachea is central
see if the chest is equally and bilaterally expanding
get the saturation of the patient - if no history of retaining then target should be aimed at above 94 percent via a non regrettable mask up to 15 L of oxygen
auscultate the lungs and percuss it
and act according tot he clinical findings - if i feel the chest is wheezy
i would give stat nebs
and IM hydrocortisone
CHECK FOR PEFR if the patient is able to give one
ABG
CXR aswell
C - check the capillary refill time
check the pulse - is it regular , volume ,
GET AN ECG
check the BP
put in two large bore IV annular
at the same time take bloods - abc , ue , , eft , crp , coal , group and save and if speaking
D-DIMER test
temperature blood cultures
auscultate the heart
D - check AVPU and GCS
check glucose
check the temperature
E - expose the patient keeping in mind the patients dignity
and check for any signs of DVT
any sings of infective changes or collections
any trauma or fractured ribs
how to manage life threatening asthma ?
GIVE OXYGEN is important
up to 15 L in NBRM
with pulseoximery mentoring and telemetry
give back to back nebulisers
salbutamol and ipratropium
give IM hydrocortisone STAT / or oral prednisolone 40-50mg
give IM magnesium 2mg STAT
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after this see how the patient is doing and responding
escalate it to my senior - medical registrar/ CCOT AND ITU - this taint might need ITU input as pragmatic approach if further managment fails
repeat the ABG and PEFR
bedisde observation is important to see if the patient is not tiring
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IV aminophyline can be administered
patient has to be on cardiac monitoring with these kind of drugs as it can cause cardiac arrhythmia
and regular bloods - can cause hypokalaemia
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if patient not responding immediate ITU support
patient would need sedation and intuition and ventilation
or ECMO
criteria that would prompt you to discuss this patient with ITU?
British Thoracic Guidelines, I would refer any patient that is:
requiring ventilatory support
with acute severe or life-threatening asthma, who is failing to respond to therapy, as evidenced by:
deteriorating PEF
persisting or worsening hypoxia
hypercapnia
ABG analysis showing decreasing pH or increasing H+
exhaustion, feeble respiration
drowsiness, confusion, altered conscious state
respiratory arrest.
The patient’s sister has arrived on the ward and your consultant has asked you to talk to them about what has happened. What should you consider before talking to the patient’s relative?
MAKE SURE I HAVE THE NECESSARY INFORMATION
discuss the case with my consultant and my registrar just so i do not give false information, speak without UNDERSTANDINFG or UNRELAISTIC EXPECTATIONS
FIND A QUEIT PLACE
ask about their perception what has been happening so far with the relative
and what they know so far
as if they would like nay body else present
discuss the the clinical findings , what was found on diagnostics
prepare the patient for the bad news with a warning shot BEFORE TALKING ABOUT THE PERI ARREST
MAKE SURe i don’t involve medical jargon and , its concise with enough pauses so they can digest
make then umderstand how now we are best supporting the patient with managmnet
as if they have any question
and if these are questions i cannot answer i would ask if they would like to speak to someone senior who can best explain
give a brief summary of everything discussed
and end it with empathy
collapse whilst you are on the ward. What would you do?
immediately put out an arrest call in 2222
do my ae and see if i can feel a pulse and if there is work of breathing
if not go onto my ALS protocol
if i do see there is pulse and work of breathing do my quick ae -and address clinical concerns as i meet them , immediately call
i would also cal ITU and CCOT and my medical registrar for support
get CXR - to RULE OUT TENSION PNEUMOTHORAX
(CXR tracheostomy’s and mediastinum shifts to contralateral side)
asthma management in adults ?
step 1 - SABA
step 2 - SABA and ICS
step 3 - SABA
ICS +montelukast (leukotriene receptor antagonist)
step 4
SABA +/ LTRA
low dose ICS and LABA
step 5
SABA +/ LTRA
MART - (maintenance and reliever therapy )
that includes low dose ICS
LABA has a fast-acting component (for example, formoterol)
step 6
SABA +/ LTRA
medium dose ICS MART
(or consider changing back to a fixed dose of moderate dose ICS and a separate LABA)
step 7
SABA +/- LTRA
increase ICS to high dose MART
trail of additional drug such as LAMA or theophylline
